The U.S. National Transportation Safety Board (NTSB) has determined that a private text conversation was one of the factors that contributed to a series of poor decisions resulting in the August 2011 crash of an Air Methods Eurocopter AS350 B2 in Mosby, Mo. Four people died as a result of the accident, including the pilot, James Freudenberg. According to NTSB, in addition to being distracted from texting, three other factors contributed to the crash—fatigue, training, and taking off with less fuel than needed resulting in the pilot failing to “make the flight control inputs necessary to enter an autorotation,” an emergency maneuver required within about two seconds after the loss of engine power in order to land safely.

The agency released a report regarding the LifeNet-operated AS350 that reveals the pilot engaged in a text conversation while conducting mandatory pre-flight checks, prior to accepting a mission to transport a patient from a hospital in Bethany to a Liberty, Mo. hospital about 62 miles away.

After departing the Air Methods base, the pilot reported having two hours’ worth of fuel, but then reported having only about 30 minutes of fuel remaining once he reached the first hospital, according to the safety board. An examination of the pilot’s cell phone records caused NTSB to cite distraction from texting as a contributing factor, as Freudenberg made several calls and text messages during the helicopter’s pre-flight inspection, as well as in flight to the first hospital and while he was making “mission-critical decisions” about delaying the operation due to the fuel situation.

After arriving at the first hospital, the pilot was scheduled to fly the AS350 to a nearby airport for refueling. The helicopter ran out of fuel and the engine lost power within sight of the airport, and Freudenberg did not respond with the necessary flight inputs for autorotation. Investigators found that because of a lack of specific guidance in FAA training materials, the pilot may not have been aware of specific control inputs needed to enter an autorotation at cruise speed.

The agency is recommending FAA suspend the use of non-flight-related portable electronic devices (PEDs) during flight and safety-critical inspections, along with eight other safety recommendations resulting from the crash investigation related to updating flight manuals, informing other pilots about the circumstances of this accident, and installing crash-resistant flight recorder systems on all turbine-powered aircraft.

The findings highlight “what is a growing concern across transportation distraction and the myth of multi-tasking,” NTSB Chairman Deborah Hersman noted in a statement. “When operating heavy machinery, whether it’s a personal vehicle or an emergency medical services helicopter, the focus must be on the task at hand: safe transportation.”